About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Do you have any allergies?
If yes, please provide details
Have you ever had an allergic or anaphylactic reaction to naproxen, aspirin, ibuprofen or any other medication?
If yes, please provide details
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Women only: are you currently breast-feeding?
Do you have any problems with your stomach or gut (intestine), such as an ulcer or bleeding?
Do you have high blood pressure, diabetes, high cholesterol or are you a smoker?
If yes, please provide details
Did you start experiencing period pain more than a year after after starting menstruation?
Do you have any symptoms?
If yes, please provide details
Do you have any autoimmune condition such as systemic lupus erythematosus?
Do you have any recent or past medical history of note?
If yes, please provide details
Do you have any liver problems?
If yes, please provide details
Do you have any kidney problems?
If yes, please provide details
Please provide details in this box here...
Have you been told by your doctor you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
If yes, please provide details
Please provide details in this box here...
Do you have any heart problems?
If yes, please provide details
Do you have difficulties conceiving or are you undergoing investigation of fertility?
Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)?
Do you have a history of gastrointestinal diseases such as ulcerative colitis or Crohn's disease?
Do you have asthma, allergies (like hay fever), polyps or rhinitis?
Do you have any other recent or past medical history of note?
If yes, please provide details
Please list all your current prescription medication including any medication you buy over the counter...
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The Agreement
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
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Do you agree to the following?
You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
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